Registration

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info (Not Contact #1 or #2)

Students entered below will be added to your family's account

Add New Student #1:

(Show-Hide Details)

	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	What are your main goals?:*
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):

Questions/Options:


Is your child able to float on a back without support? *
Is your child able to put face in water? *
Does your child know some basic Freestyle/Backstroke? *

Additional Information: